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COVID-19 TESTING - PATIENT INTAKE FORM

We appreciate your compliance with this new regulation. Please print prior to appointment. 


LAST NAME: ____________________________ FIRST NAME: _____________________ 

ADDRESS: ____________________________________________________________________________________________ CITY: __________________________________

STATE: ______________________________

ZIP CODE: _____________

COUNTY: _______________________________ PHONE NUMBER: _____________________________________________ 

TEST QUESTION

ANSWER OPTIONS

NOTE/DETAILS

First Test?
Employed in Healthcare?

Date of Onset: Hospitalized? ICU?

Pregnant? 

Are you scheduled for a procedure/operation in the near future?

  

Symptomatic as defined by the CDC?

___ Yes ___ No ___ Unknown

CDC Symptoms: Fever/chills, cough, shortness of breath, fatigue, muscle/body aches, headache, new loss of taste or smell, congestion/runny nose, sore throat, nausea/vomiting, diarrhea.

    

Resident in a congregate care setting?

___ Yes ___ No ___ Unknown

Including nursing homes, residential care for people with intellectual and developmental disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care or other setting.